CONFOCAL LASER ENDOMICROSCOPY FOR THE ......CONFOCAL LASER ENDOMICROSCOPY FOR THE DETECTION OF...
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CONFOCAL LASER ENDOMICROSCOPY FOR THE DETECTION OF MUCOSAL CHANGES IN ILEAL POUCH AFTER RESTORATIVE PROCTOCOLECTOMY Crosta C 1 , Trovato C 1 , Sonzogni A 2 , Fiori G 1 , Ravizza D 1 , Rossi M 1 , Tamayo D 1 , Botti F 3,4 , Carrara A 3,4 , Zefilippo A 3 , Viale G 2 , Contessini-Avesani E 3,4 1 Division of Endoscopy and 2 Division of Pathology, European Institute of Oncology, Milan, Italy. 3 2nd Division of General Surgery and 4 Department of Surgical Sciences, IRCCS Maggiore Hospital, Milan University, Milan, Italy BACKGROUND AND AIMS Confocal laser endomicroscopy is a novel technique to analyze living cells during ongoing endoscopy. Total proctocolectomy with ileal pouch anal anastomosis is the surgical procedure of choice for the management of ulcerative colitis and familial adenomatous polyposis. Pouchitis, a non-specific inflammation of the ileal reservoir, and dysplasia may affect the pouch after surgery. The aim of the present study was to assess the suitability of confocal laser endomicroscopy for the in-vivo diagnosis of mucosal changes in the ileal pouch. METHODS Video endoscopy and fluorescein-aided endomicroscopy (EC-3870CIFK; Pentax, Tokyo, Japan) were performed in the four quadrants of the proximal, middle and distal parts of the pouch in 18 patients. Any lesions, if present, were also analyzed. Targeted biopsies were taken. Confocal images and histological findings were analyzed for the presence of villous atrophy, inflammation, ulceration, colonic metaplasia and dysplasia. At endomicroscopy these parameters were defined according to a new Pouchitis Confocal Endomicroscopy Scale (see Table). Considering the presence of abnormalities in at least one of the above parameters in at least one of the confocal image/biopsy from the reservoir, sensitivity, specificity, positive and negative predictive values, and accuracy rates were calculated for the prediction of morphological changes of the pouch. RESULTS CONCLUSIONS On the basis of these preliminary results, the presence of morphological changes of the pouch could be predicted with an accuracy of 94,4%. Endomicroscopy may be helpful in evaluating the ileal reservoir after restorative proctocolectomy and may lead to a significant improvement in the in-vivo surveillance of the pouch. REFERENCES Hoffman A, Goetz M, Vieth M, et al. Confocal laser endomicroscopy: technical status and current indications. Endoscopy 2006;38:1275-83 Kiesslich R, Burg J, Vieth M, et al. Confocal laser endoscopy for diagnosing intraepithelial neoplasias and colorectal cancer in vivo. Gastroenterology 2004;12:706-13 Gionchetti P, Amadini C, Rizzello F, et al. Diagnosis and treatment of pouchitis. Best Pract Res Clin Gastroenterol 2003;17:75-87 Ettorre GM, Pescatori M, Panis Y, et al. Mucosal changes in ileal pouches after restorative proctocolectomy for ulcerative and Crohn's colitis. Dis Colon Rectum 2000;43:1743-8 Das P, Johnson MW, Tekkis PP, Nicholls RJ. Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Colorectal Dis 2007;9:15-27 Histology Confocal Parameters Correlation between confocal images and histology 18 18 No Dysplasia 15 12 Yes 3 6 No Colonic Metaplasia 6 3 Yes 12 15 No Ulceration 6 3 Severe 11 10 Mild 1 5 Absent Inflammation 7 4 Severe 8 11 Mild 3 3 Absent Villous atrophy Before surgery Ileal pouch Before surgery, villi appear regular, finger- and leaf-like. They are packed very densely, almost “sticking” to each other. Enterocyte brush border is well defined. The surface shows many transversal furrows with numerous goblet cells between enterocytes (black spots within the epithelial layer). Normal ileal pouch villi present the same characteristics but are less densely packed with fewer transversal furrows. Absent Image examples Interpretation Confocal diagnosis Parameters Presence of like-round shaped colonic crypts. Yes Colonic Metaplasia Devoid of villi with collars of enterocytes around crypt openings. Severe Villi are folded and irregular in shape. Increased space between villi is recognized. The enterocyte brush border is not well defined. The surface is almost smooth. Goblet cells are depleted. Mild Villous atrophy e-mail: [email protected] Image examples Interpretation Confocal diagnosis Parameters Presence of irregular cell architecture with little or no mucin and black irregular cells. Yes Dysplasia Severe inflammation with superficial ulceration and absence of gland component. Yes Ulceration Severe cellular infiltration with severe reduction of gland component Severe Presence of mild/moderate cellular infiltration in the lamina propria and dilated vessel. At endomicroscopy it is not possible to distinguish acute and chronic inflammation. Mild See normal morphology of ileal mucosa Normal presence of inflammatory elements in the lamina propria. Absent Inflammation POUCHITIS CONFOCAL ENDOMICROSCOPY SCALE Presence of morphological abnormalities of the pouch 18 16 2 Total 17 1 Total 16 0 Yes 1 1 No Yes No Confocal Histology 9.5-90.5 50.0 NPV 74.2-99.0 94.4 Accuracy 80.6-100.0 100.0 PPV 20.7-100.0 100.0 Specificity 73.0-99.0 94.1 Sensibility IC-95% Endoscopic appearance 11 normal 5 mild pouchitis 2 severe pouchitis
Transcript of CONFOCAL LASER ENDOMICROSCOPY FOR THE ......CONFOCAL LASER ENDOMICROSCOPY FOR THE DETECTION OF...
CONFOCAL LASER ENDOMICROSCOPY FOR THE DETECTION OF MUCOSAL CHANGES IN ILEAL POUCH AFTER RESTORATIVE PROCTOCOLECTOMY
Crosta C1, Trovato C1, Sonzogni A2, Fiori G1, Ravizza D1, Rossi M1, Tamayo D1, Botti F3,4, Carrara A3,4, Zefilippo A3, Viale G2, Contessini-Avesani E3,4
1Division of Endoscopy and 2Division of Pathology, European Institute of Oncology, Milan, Italy. 32nd Division of General Surgery and 4Department of Surgical Sciences, IRCCS Maggiore Hospital, Milan University, Milan, Italy
BACKGROUND AND AIMSConfocal laser endomicroscopy is a novel technique to analyze living cells during ongoing endoscopy. Total proctocolectomy with ileal pouch anal anastomosis is the surgical procedure of choice for the management of ulcerative colitis and familial adenomatous polyposis. Pouchitis, a non-specific inflammation of the ileal reservoir, and dysplasia may affect the pouch after surgery. The aim of the present study was to assess the suitability of confocal laser endomicroscopy for the in-vivo diagnosis of mucosal changes in the ileal pouch.
METHODSVideo endoscopy and fluorescein-aided endomicroscopy (EC-3870CIFK; Pentax, Tokyo, Japan) were performed in the four quadrants of the proximal, middle and distal parts of the pouch in 18 patients. Any lesions, if present, were also analyzed. Targeted biopsies were taken. Confocal images and histological findings were analyzed for the presence of villous atrophy, inflammation, ulceration, colonic metaplasia and dysplasia. At endomicroscopy these parameters were defined according to a new Pouchitis Confocal Endomicroscopy Scale (see Table). Considering the presence of abnormalities in at least one of the above parameters in at least one of the confocal image/biopsy from the reservoir, sensitivity, specificity, positive and negative predictive values, and accuracy rates were calculated for the prediction of morphological changes of the pouch.
RESULTS CONCLUSIONSOn the basis of these preliminary results, the presence of morphological changes of the pouch could be predicted with an accuracy of 94,4%.
Endomicroscopy may be helpful in evaluating the ileal reservoir after restorative proctocolectomy and may lead to a significant improvement in the in-vivo surveillance of the pouch.
REFERENCES
Hoffman A, Goetz M, Vieth M, et al. Confocal laser endomicroscopy: technical status and current indications. Endoscopy 2006;38:1275-83
Kiesslich R, Burg J, Vieth M, et al. Confocal laser endoscopy for diagnosing intraepithelial neoplasias and colorectal cancer in vivo. Gastroenterology 2004;12:706-13
Gionchetti P, Amadini C, Rizzello F, et al. Diagnosis and treatment of pouchitis. Best Pract Res Clin Gastroenterol 2003;17:75-87
Ettorre GM, Pescatori M, Panis Y, et al. Mucosal changes in ileal pouches after restorative proctocolectomy for ulcerative and Crohn's colitis. Dis Colon Rectum 2000;43:1743-8
Das P, Johnson MW, Tekkis PP, Nicholls RJ. Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Colorectal Dis 2007;9:15-27
HistologyConfocalParametersCorrelation between confocal images and histology
1818NoDysplasia1512Yes36No
Colonic Metaplasia
63Yes1215No
Ulceration
63Severe1110Mild15Absent
Inflammation
74Severe811Mild33Absent
Villous atrophy
Before surgery Ileal pouchBefore surgery, villi appear regular, finger- and leaf-like. They are packed very densely, almost “sticking” to each other. Enterocyte brush border is well defined. The surface shows many transversal furrows with numerous goblet cells between enterocytes (black spots within the epithelial layer). Normal ileal pouch villi present the same characteristics but are less densely packed with fewer transversal furrows.
Absent
Image examplesInterpretationConfocal diagnosisParameters
Presence of like-round shaped colonic crypts.YesColonicMetaplasia
Devoid of villi with collars of enterocytes around crypt openings.
Severe
Villi are folded and irregular in shape. Increased space between villi is recognized. The enterocyte brush border is not well defined. The surface is almost smooth. Goblet cells are depleted.
Mild
Villous atrophy
e-mail: [email protected]
Image examplesInterpretationConfocal diagnosisParameters
Presence of irregular cell architecture with little or no mucinand black irregular cells.
YesDysplasia
Severe inflammation with superficial ulceration and absence of gland component.
YesUlceration
Severe cellular infiltration with severe reduction of gland component
Severe
Presence of mild/moderate cellular infiltration in the lamina propria and dilated vessel. At endomicroscopy it is not possible to distinguish acute and chronic inflammation.
Mild
See normal morphology of ileal mucosaNormal presence of inflammatory elements in the lamina propria.
AbsentInflammation
POUCHITIS CONFOCAL ENDOMICROSCOPY SCALE
Presence of morphological abnormalities of the pouch
18
16
2
Total
171Total
160Yes
11No
YesNo
Confocal
Histology
9.5-90.550.0NPV74.2-99.094.4Accuracy
80.6-100.0100.0PPV20.7-100.0100.0Specificity73.0-99.094.1SensibilityIC-95%
Endoscopic appearance11 normal5 mild pouchitis2 severe pouchitis
